W06 - PAEDS: GI, Infant Feeding, Liver, Growth & Endocrine Flashcards
Causes of Vomiting in Children
Enteric pathogens
Infection
Stimuli / Fear
Head injury / ICP = morning vomiting w/ retching
Inner ear stimuli
Metabolic derangements
Haemetemesis: peptic ulcers, portal hypertension
GORD in Paediatrics
effortless vom.
Location of the vomitting centre
Medulla oblongata
Common causes of vom in infants
GOReflux
Cow’s Milk allergy
Infection
Intestinal obstruction
+ pyloric stenosis = olive tumour = projectile non billous vom after feed
+ overfeeding
Common causes of vom in childrena nd YA
- gastroenteritis
- infection
- raised ICP
- Obstruction
- Coeliac
+h pylori
+ DKA
+ cyclical vomiting syndrome
+ bulimia
Common causes of vom in childrena nd YA
- gastroenteritis
- infection
- raised ICP
- Obstruction
- Coeliac
+h pylori
+ DKA
+ cyclical vomiting syndrome
+ bulimia
Pyloric stenosis
olive tumour, non-billous projectile vom., M>F
- wt loss
- dehydration
*HYPOKALEMIC
* HYPOCHLOREMIC METABOLIC ALKALOSIS
> Fluid resus
Pyloromectomy
Effortless Vomiting
almost always dt GOReflux, very common, self-limiting, worse at 4-6mos, improves by 1st year
- laxed lower oesoph. sphincter
- exacerbated by nature of liquid foods
- resp symptoms: apnoea, cough, wheeze, chest infections
- sandifer’s syndrome = dystonic positioning dt reflux
*pH meter = looking at how often pH drops below 4
*pH study = combined w/ meter, to detect significant reflux
* endo. (reflux, eosophagitis), vid fluoroscopy (aspiration pneumon.), barium swallow (hiatus)
> feeding advice: thickener etc.
nutritional support: NG tube
medical: feed thickener, prokinetic drugs, ACID SUPPR. DRUGS
Sx: for resistant, and failure to thrive, aspiration, oesophpagitis
Indication for upper GI endoscopy in children
growth faltering
persistent sympoms
unresponsive to anti-reflux rx
*requires GA
Bilious vomiting
red flag!!
*intestinal obstr. dt
- atrsia
- malrotation, interssuspection, ileus, crohns + strictures
- abdo xr
contrast meal
sx: exploratory lap.
Definition of chronic diarrhoea
4 or more stools per day for more than 4 weeks
- <1w = acute diarr.
2-4w = persistent
Significance of nocturnal defecation in chronic diarr.
suggestive of organic path.
OSMOTIC vs SECRETORY DIARRHOEA
OSMOTIC
- small stool volume, responds to fasting
- low in metabolites and ions
SECRETORY
- large volume, continuous despite fasting
- high in metablites and ions.
Fat malabs and chronic diarrhea in children
PANCREATIC
- lack of lipase = steatorrhoea
- CF
HEPATOBILIARY
- chronic liver disease
- cholestasis
Commonest cause of malabs in children
Coeliac Disease
* symptomatic children are tip of iceberg
* latent, genetics testing but negative predictive value
- dermatitis herpatiformis, other auimm conditions: IDDM
- short stature, failure to thrive
*anti-TTG,
+vantiendomysial, serum igA
DUODENAL BIOPSY
* abdo bloatedness
if symptomatic, positive serology and genetics, can be diagnosed WITHOUT biopsy
* if any serology is not present, requires endoscopy.
> GF diet
Significance of toddler’s diarrhea
well
undigested veg in stool
= chronic non-specific toddlers diarrhea
will improve with age
Constipation vicious cycle (organic cause)
constipation => large hard stool => pain/anal fissure => withholding of stool
+ social causes too: diet, xs milk
+ physical: intercurrent illness, medication
+ 2º to psychological
Management approaches to constipation
> Dietary - social
> Ensure toilet a pleasant experience
* reward good behaviour
> osmotic lax (lactulose)
stimulant lax (senna etc)
isotonic laxatives (movicol)
- provide adequate tx until no longer required
?compliance, sfx monitoring
!megarectum
> stimulatory suppositories
Significance of crohns in scottish children
incidence has been increasing in the last 20 years, panenteric disease most common thus more widespread.
!WT LOSS
!GROWTH FAILURE = growth and sexual development disruption
!ABDO PAIN
extramanifs:
-erythema nodosum
- oral changes: rolled edge ulcer
- perianal tags and fissures
anemia, thrombocytosis, raised ESR
* stool calprotectin
* raised CRP, low albumin
Vs UC
diarrhoea
rectal bleeding
abdo pain
Colitis red flags
- nocturnal diarrhoea
- bloody diarrhoea
UC in Children
not as common in children
diarrhoea (nocturnal)
rectal bleeding
abdo pain
*pancolitis more common - more widespreadextensive phenotype
Investigations & mgmt in paed UC or Crohns
- radiology (crohns)
- MRI altnernatively USS for younger
- barium meal (younger but rarely)
- endoscopy
- colonoscopy & upper GI: ALWAYS ILEAL COLONOSCOPY
- mucosal biopsy
- capsule enteroscopy
-enteroscopy
UC: crypt abscess, disordered crypts histology
CD: serpingous ulcer: slimy snail-like, granulomatous histology
> remission
correct nutritional deficiencies
maintain normal growth and development - steroid risk
> > (1) nutritional rx for crohns, space food, liquid therapy etc. - aim for abs. in upper GI. + pred
(2) steorid sparing: azathioprine, mtx.
(3) biologics)
anti-inflamm, imm suppr., biologics = used to get remission for relapsing flare-up
immune modulation
sx: stricture
Investigations & mgmt in paed UC or Crohns
- radiology (crohns)
- MRI altnernatively USS for younger
- barium meal (younger but rarely)
- endoscopy
- colonoscopy & upper GI: ALWAYS ILEAL COLONOSCOPY
- mucosal biopsy
- capsule enteroscopy
-enteroscopy
UC: crypt abscess, disordered crypts histology
CD: serpingous ulcer: slimy snail-like, granulomatous histology
> remission
correct nutritional deficiencies
maintain normal growth and development - steroid risk
> > (1) nutritional rx for crohns, space food, liquid therapy etc. - aim for abs. in upper GI. + pred
(2) steorid sparing: azathioprine, mtx.
(3) biologics)
anti-inflamm, imm suppr., biologics = used to get remission for relapsing flare-up
immune modulation
sx: stricture
To compare breast and formula feeding
a
To explain the management of cow’s milk protein allergy
> NUTRAMIGEN
APTAMIL
(2)
> sma: AMINO ACID BASED FEEDS
* SEVERE COLITIS/ENTEROPATHY
+APTAMIL PEPTI SYNEO: COWLS MILK PROTEIN WITH ADDED PROBIOTIC
+ NEOCATE SYNEO “”
+ neocate junior: amino acid for children 1yr+ with allergy
*SOYA INFANT FORMULA: dental caries risk, phytoestrogens risk, cross-react with cows milk
+ENSURE CALCIUM REQUIREMENTS ARE MET.
Avg term infant
3.3kg
Infant Nutrition
high risk for malnutrition
*human milk fortifiers: dietary supplement
Avg weight gain in infants
0-3months 200g per week
3-6 months 150g per week
6-9 months 100g per week
9-12 months 75-50g per week
x2 weight by 6mos and x3 by 1 year
*after 1ur, 2kg, and 5cm/year until puberty
Know the clinical manifestations of paediatric liver disease
JAUNDICE >40-50umol/l
- prehepatic jaundice = unconjugated
- intrahepatic = mixed
- posthepatic jaundice = conjugated (cholestasis)
Incidental finding of abdn bloos
Chronic liver disease symptoms/signs
- growth failure
- ascites, splenomegaly w/ portal HT
- spider naevi
- fat malabs, deficienvy of fat-soluble vitamins
- rickets (vit d def.)
Be aware of the biochemical markers used in the assessment of liver disease in chiildren
Total bilirubin
Split: Direct + Indirect Bilirubin
ALT/AST: hepatitis
Alkaline phosphatase: biliary disease
GGT: biliary disease
Describe the causes of unconjugated and conjugated hyperbilirubinaemia and prolonged neonatal jaundice (including biliary atresia)
<24hr old early neonate jaundice
= haemolysis, sepsis
24hr-2w intermediate neonate
= physiological, breast milk, sepsis, haemolysis
2w+ prolonged
= extrahepatic obstruction, neonatal hepatitis (A,B,C), hypothyroidism, breast milk
compl: KERNICTERUS: deposits of uncon. bili in brain = ENCEPHALOPATHY, late choreoathetoid cerebral palsy = developmental disruption
> PHOTOTHERAPY promotes conjugation to water-soluble
Physiological jaundice in neonates
- relative polycythemia
- relative immaturity of liver funct.
= unconjugated jaundice
Breast milk jaundice
unclear but ?UDP inhibition via progesterone metbaolite or ?increased enterohepatic circulation
= unconjugated jaundice
Common abn conjugation of bilirubin in infant jaundice
GILBERT’S DISEASE
Prolonged infant jaundice
persisting beyond 2w of life
*SPLIT BILIRUBIN TEST
* ASSESS STOOL = PALE = CONJUGATED jaundice
- Biliary atresia = conj. jaundice; pale stools + dark piss
> kasai poroenterostomy
> liver transplant - identify and dx early to ensure prompt tx and plan
- USS, lier biopsy
- Choledochal cyst = cong. jaundice; pale
- USS
- Intrahepatic cholestasis, dysmorphism, congenital cardiac disease
Bone Age Assessment in Paeds
Tanner-Whitehouse (TW) method involves the scoring of each carpal bone, the radius and ulna leading to a total score, from which age can be estimated.
Common Causes of short stature
-familial
-constitutional
- SGA / UGR
+IGR deficiency = isolated GH def.
* MRI
> GH replacement
Tanner Staging
*Stage I = prepubertal
* Stage II = start of puberty
*breast budding = B2
Testicular enlargement = G2-T 4ml
Ages of Puberty
Females begin with breast budding at ~10yo
Menarche later development.
Whereas males begin with testicular growth onset at 11/12yo. Male growth spurt later.
Abn Growth: Short Stature - pathological
Chronic illness
Iatrogenic steroid use
Psychosocial disturbance
SIMPLE OBESITY
- Thyroid def.
- Turner Syndrome: female short stature, ovarian dysgenesis
- karyotyping
- Prader-willi syndrome: short stature, hypogonadism, obesity in childhood, infantile hypotonia/feeding problem
- Noonan syndrome: congenital heart disease
- Achondroplasia - short limb dwarfism
- long bones dont grow properly
Early sexual development
*abn steroid prod. = congenital adrenal hyperplasia
- CENTRAL PRECOCIOUS PUBERTY
- breast / testicular development
- growth spurt
- advanced bone age
- MRI = ?pit. lesion
- PRECOCIOUS PSEUDOPUBERTY
- secondary charac. development
- independent of LH/FSH
- exclude congenital adrenal hyperplasia
DM in Children
PRESENTS T1DM.
* ensure early dx and mgmt. prevent DKA. prevent LT complications and disability.
t4
thirsty
tired
thinner
toilet+++
*bedwetting REDFLAG
+candidiasis
+ skin infections
+ heavier nappies
+ blurred vision
DKA = ap blood glc
11MMOL+ = DM
=> referral
